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Full text of "A Study of Infant Mortality Among American Indians"

A Study of Infant Mortality Among 

American Indians & Alaska Natives from 

the 1983 Linked Birth/Infant Death Data Set 

February, 1992 



Office of fvuriL . Jt> Center 

Knowiecgt Center 

1101 Wootton Parkway, Suite 650 

Rockville, MD 20852 

1-800-444-6472 



U.S. Department of Health and Human Services 

Public Health Service 

Indian Health Service 

Office of Planning, Evaluation, and Legislation 

Division of Program Statistics 

Demographic Statistics Branch 



5600 Fishers Lane, Room 6-41 

Rockville, Maryland 20857 

(301)443-1180 



o 

O 
S- 



fOtioi^lf 



Analysis and Computer Programming by: 

Linda Querec, Statistician 
Demographic Statistics Branch 



Analytical Review by: 

Aaron Handler, Chief 
Demographic Statistics Branch 



Typing (text, tables & charts) by: 

Barbara Moore, Statistical Assistant 
Demographic Statistics Branch 

Priscilla Sandoval, Secretary 
Division of Program Statistics 



TABLE OF CONTENTS 

PAGE 

INTRODUCTION 1 

SOURCES AND LIMITATIONS OF DATA 1 

RACE REPORTING FOR INFANT DEATHS 2 

Race Reporting Procedures and Classification Methods . . 3 
Underreporting of American Indian/Alaska Native Infant 

Deaths 4 

Infant Mortality Rates from the Linked File Compared to 

Registration Data 6 

CHARACTERISTICS OF INFANT DEATHS 

Health Characteristics of Infant Deaths 8 

Age at Death 8 

Birth Weight 8 

Cause of Death 9 

Preventable Infant Mortality 10 

Factors During Pregnancy and Delivery Relating to Health 

of the Infant 11 

Prenatal Care 11 

Attendant at Birth and Place of Delivery 11 

Apgar Score 11 

Plurality 12 

Age of Mother 12 

Education of Parents 13 

Marital Status of Mother 13 

Live Birth Order 13 

APPENDIX A 

National Center for Health Statistics Procedures 

for Coding Race of the Child When the Parents Are 

of Different Races 15 

APPENDIX B 

Indian Health Service Area Offices 17 

TABLES : 

1. Number of American Indian & Alaska Native Births and 
Infant Deaths by State of Residence of Mother for Each 
Reservation and Nonreservation State, From the 1983 

Linked Study and Regular Registration Data 18 

2. Number and Percent of American Indian & Alaska Native 
Births by Race of Parents, 1983 Registration Data ... 20 



PAGE 

3. Number of Infant Deaths and Infant Mortality Rates 
by Age at Death, American Indian & Alaska Native, 

1983 Linked Study, Compared to 1983 Registration Data . 21 

4. Number of Infant Deaths and Infant Mortality Rates 
by Age at Death, American Indian & Alaska Native, 
Compared to Selected Races, 1983 Linked Study 22 

5. Number of Infant Deaths and Infant Mortality Rates 
by Selected Birth Weight Categories, American 
Indian & Alaska Native, Compared to Selected Races, 

1983 Linked Study 2 3 

6. Number of Infant Deaths and Infant Mortality Rates 
by Birth Weight, American Indian & Alaska Native, 
Compared to Selected Races, 1983 Linked Study 24 

7. Number of Neonatal and Postneonatal Deaths and Infant 
Mortality Rates by Birth Weight, American Indian & 
Alaska Native, Compared to Selected Races, 198 3 

Linked Study 2 5 

8. Number of Infant Deaths and Infant Mortality Rates 
by Cause of Death, American Indian & Alaska Native, 

1983 Linked Study, Compared to 1983 Registration Data . 26 

9. Number of Infant Deaths and Infant Mortality Rates by 
Cause of Death, American Indian & Alaska Native, 

Compared to Selected Races, 1983 Linked Study 2 7 

10. Number of Infant Deaths and Infant Mortality Rates by 
Month Prenatal Care Began, American Indian & Alaska 
Native, Compared to Selected Races, 1983 Linked Study . 28 

11. Number of Infant Deaths and Infant Mortality Rates by 
Attendant at Birth and Place of Delivery, American 
Indian & Alaska Native, Compared to Selected Races, 

1983 Linked Study 2 9 

12. Number of Infant Deaths and Infant Mortality Rates by 
1 Minute Apgar Score, American Indian & Alaska Native, 
Compared to Selected Races, 1983 Linked Study 3 

13. Number of Infant Deaths and Infant Mortality Rates by 
5 Minute Apgar Score, American Indian & Alaska Native, 
Compared to Selected Races, 1983 Linked Study 31 



j.1 



PAGE 

14. Number of Infant Deaths and Infant Mortality Rates by 
Plurality, American Indian & Alaska Native, Compared 

to Selected Races, 1983 Linked Study 32 

15. Number of Infant Deaths and Infant Mortality Rates by 
Age of Mother, American Indian & Alaska Native, 

Compared to Selected Races, 1983 Linked Study 3 3 

16. Number of Infant Deaths and Infant Mortality Rates by 
Mother's Education for Women 18 Years or Older, 
American Indian & Alaska Native, Compared to Selected 
Races, 1983 Linked Study 34 

17. Number of Infant Deaths and Infant Mortality Rates by 
Father's Education for Men 18 Years or Older, 
American Indian & Alaska Native, Compared to Selected 
Races, 1983 Linked Study 35 

18. Number of Infant Deaths and Infant Mortality Rates by 
Marital Status of Mother, American Indian & Alaska 
Native, Compared to Selected Races, 1983 Linked 

Study 3 6 

19. Number of Infant Deaths and Infant Mortality Rates by 
Live Birth Order, American Indian & Alaska Native, 
Compared to Selected Races, 1983 Linked Study 3 7 



FIGURES: 

1. Infant Mortality Rates by Age of Death 
for American Indians/Alaska Natives, 

1983 Registration Data and 1983 Linked Study 39 

2. Infant Mortality Rates by Age at Death 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 

3. Infant Mortality Rates for Infants 
Weighing 2500 Grams or More, 
American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 41 

4. Infant Mortality Rates for American 
Indians/Alaska Natives by Cause of Death, 

1983 Registration Data and 1983 Linked Study 4 2 

5. Infant Mortality Rates by Cause 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 3 

iii 



PAGE 

6. Infant Mortality Rates by Month Prenatal Care 
Began for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 4 

7. Infant Mortality Rates by 1 Minute Apgar Score 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 5 

8. Infant Mortality Rates by 5 Minute Apgar Score 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 6 

9. Infant Mortality Rates by Mother's Education 
for Mothers Age 18 Years or Older, 
American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 7 

10. Infant Mortality Rates by Marital Status of Mother 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 8 

11. Infant Mortality Rates by Live Birth Order 
for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 4 9 



IV 



INTRODUCTION 

The Linked Birth/Infant Death Data Set offers two unique 
opportunities unavailable prior to its preparation. First, it 
affords a means to estimate the level of misreporting of race on 
State death certificates of American Indian and Alaska Native 
infant deaths. (The term "Indian" will be used to denote the 
American Indian and Alaska Native population throughout this 
report.) Secondly, it provides the opportunity to analyze for 
infant deaths regardless of race, demographic, socioeconomic, and 
health data contained on the birth certificate but not the death 
certificate. 

The first public use version of a national linked file was 
made available by the National Center for Health Statistics (NCHS) 
for the 1983 live birth cohort. NCHS plans to issue these public 
use tapes routinely on an annual basis. Currently, public use 
tapes containing linked file data are available for the 1984, 1985, 
and 1986 birth cohorts. 

The Indian Health Service (IHS) had only the 1983 Linked File 
for use when preparing this report. The data presented here should 
be interpreted with caution because of the small number of infant 
deaths under review for this one-year period. 



SOURCES AND LIMITATIONS OF DATA 

IHS normally prepares its Indian infant mortality statistics 
from the routine annual vital event data tapes it receives from 
NCHS. The tapes contain automated copies of records compiled from 
official birth and death certificates for all U.S. residents which 
are supplied to NCHS by the State health departments. Infant death 
records are included on the annual mortality record file provided 
to IHS as are records of decedents of all other ages. 

Infant mortality rates computed from these data tapes consist 
of "period data" as opposed to "cohort data." A period rate is 
defined as the number of infant deaths per 1,000 live births 
occurring during a one year period. The numerator and denominator 
are not exactly comparable since some of these deaths may be to 
infants born during the previous year while some of the infants 
born in that year may not die until the following year but prior to 
reaching the first birthday. Normally there is no routine linkage 
between the mortality and natality data tapes to identify which of 
the infants died. 

The Linked Birth/Infant Death Data Set used for this report 
was compiled using the 1983 live birth cohort. This cohort, by 
definition, consists of all infants born alive within the U.S. 



during calendar year 1983. NCHS created the linked file with 
assistance from the State health departments. The linked data set 
consists of two separate files. The first file, or numerator file, 
consists of records of deaths of infants born in 1983, linked with 
their live birth records. These deaths may have occurred in 198 3 
or 1984, prior to the infant's first birthday. The second file, or 
denominator file, consists of records of all live births occurring 
during 1983, and it offers the opportunity to compute infant 
mortality rates for the cohort. Therefore, infant mortality rates 
computed from the linked file are defined as the number of deaths 
of infants born during 1983 per 1,000 live births occurring in that 
year. More detailed information on preparation of the data set is 
included in the documentation issued by NCHS for the public use 
data tape 1 . 

The linkage of the birth record to the death record offers a 
wealth of new information not previously available when analyzing 
infant mortality record data. Without the linkage the only 
available information about the individual comes from the death 
certificate. Some of this information, while relevant and 
important to an adult decedent, cannot be answered for, or is 
irrelevant to, an infant. For example, usual occupation and kind 
of business or industry, while an indicator of socioeconomic status 
for an adult, obviously does not pertain to an infant. However, 
age and education of the mother and father identified on the birth 
certificate are good indications of the newborn's socioeconomic 
status. 

For infants dying during the first year of life, it is 
possible to identify health status at birth indicated by birth 
weight and Apgar score as a result of the linkage. Certain 
pregnancy and delivery items related to survival chances are 
available for analysis from the birth certificate, as well. 



RACE REPORTING FOR INFANT DEATHS 

Numerous studies have found an underreporting of infant deaths 
for Indians and for racial categories other than White or Black 2 , 3 . 



1 Public Use Data Tape Documentation - Linked Birth/Infant 
Death Data Set: 1983 Birth Cohort. U.S. Department of Health and 
Human Services, Public Health Service, Centers for Disease Control, 
National Center for Health Statistics, January 1989. 

2 F. Frost and Kirkwood K. Shy. Racial differences between 
linked birth and infant deaths records in Washington State. 
American Journal of Public Health , 70:974-976, Sept. 1980. 



'% 



Differences have been identified in linked studies by comparing 
race reported on the death certificate with race reported on the 
birth certificate for the same infant. The linked file used here 
contains the race shown on the birth certificate only, eliminating 
the possibility of a direct comparison of race reporting for the 
same infant on the birth and death certificates. An estimate of 
the extent of underreporting of Indian infant deaths can, however, 
be developed by comparing the number of infant deaths from the 
death registration system with the number from the linked file. 
Estimates of underreporting of Indian infant deaths are included in 
a later section of this report. 

Race Reporting Procedures and Classification Methods 

Different procedures are followed for reporting race on the 
birth certificate and on the death certificate. For the birth 
certificate, race of mother and father are usually provided by the 
mother at the time of delivery. For the death certificate, usually 
the funeral director provides the race of the infant based on 
personal observation or information provided by an informant, such 
as a parent or other relative. 

IHS classifies the race of the child from the birth 
certificate differently from NCHS. IHS classifies as Indian any 
birth for which the mother or the father is reported as Indian. 
This method is used by IHS because any infant born to an eligible 
Indian mother or father is eligible to receive IHS-funded health 
care services. In contrast, NCHS has coding rules which take into 
account the race of both parents (See Appendix A) . The only 
difference in identification of an Indian birth resulting from 
these two methods would occur if the mother is an Indian and the 
father is a race other than Indian or White. IHS would classify 
the birth as Indian while NCHS would classify the birth as the race 
of the father. This report conforms to the IHS method of 
classification and uses the race of mother and father rather than 
the NCHS method of classification. 

IHS reports generally show data for Indians residing in either 
the IHS Service Area or the Reservation States. The Service Area 
consists of those geographic areas in which IHS has 
responsibilities. In general, the IHS Service Area is comprised of 
counties on which an Indian reservation of a Federally recognized 
Indian Tribe or traditional Indian land is located, as well as 
counties which border these counties. Reservation States are those 
States in which at least one Federally recognized Indian 
reservation or traditional Indian land is located. There were 31 
Reservation States in 1983; currently there are 33 such States. 
Records are allocated to the Service Area based on county of 
residence. For those counties split between the Service and 
nonservice Area, a community code is used to allocate the record to 
the appropriate Area. Although the linked file contains the county 
of residence code it does not contain the community codes necessary 



to properly allocate records from split counties, so data included 
in this report are shown for infant deaths regardless of whether 
they were in the Service Area. Although it would be possible to 
limit the analysis of data to Reservation States, eliminating the 
infant deaths occurring in Nonreservation States would make the 
number of infant deaths too small for some analysis purposes. 
Therefore, tables showing health or demographic characteristics 
contain the data for all States of the United States unless 
identified otherwise. 

Underreporting of American Indian/Alaska Native Infant Deaths 

Table 1 provides a comparison of the number of Indian infant 
deaths included in the linked data set with the number reported 
through regular registration procedures. For the United States as 
a whole, the linked file identified 615 infant deaths as Indian, 
compared to only 443 identified through regular registration data, 
an additional 172 infant deaths identified through linking 
procedures. If we assume the linked file provides a more accurate 
count, the number of Indian infant deaths was approximately 3 9 
percent greater than the number actually reported on death 
certificates. 

Table 1 also shows the data by State, categorizing the States 
as Reservation and Nonreservation. For the 31 States that were 
classified as Reservation States in 1983, the linked file 
identified 37 percent more Indian infant deaths than were reported 
from death certificates, 586 compared to 427. Since 1983, Alabama 
and Massachusetts have been added as Reservation States. 

Examination of the data by State shows wide variation in 
accuracy of reporting of the number of Indian infant deaths. 
Reservation States with a large percentage difference between 
linked data and registration data (among States with at least 10 
deaths from the registration data file) included California (356 
percent) , Oklahoma (63 percent) , North Dakota (42 percent) , and 
Washington (32 percent) . Underreporting in these States is 
consistent with prior findings of an artificially low infant 
mortality rate for three IHS Areas- California, Oklahoma City, and 
Portland, compared with other Areas. California, Oklahoma, and 
Washington comprise portions of these three Areas. (Appendix B 
shows IHS Areas and the States included in each.) 

Unfortunately, some Areas are not combinations of whole States 
such that the number of infant deaths could be computed for an Area 
based on State data from the linked file. For instance, although 
the California Area includes only the State of California, the 
California Area consisted of only one-third of the Indian 
population and 28 percent of the births in the State of California 
in 1983. Therefore, we cannot extrapolate, in all cases, the 
number of deaths or an infant mortality rate from a State or a 
combination of States to an IHS Area. 



It is unclear why underreporting is more extensive in the 
three previously identified "problem" Areas. Perhaps the large 
Hispanic population in California and the heavy concentration of 
Hispanic sounding names among American Indians leads to 
misclassification as Hispanic in that State. Residence in non- 
Indian/ Anglo areas may also result in greater likelihood of 
misclassification as non-Indian. 

Table 2 shows the number and percent distribution of Indian 
births by race of parents by IHS Area from 1983 birth registration 
data. The California, Oklahoma, and Portland Areas each have the 
lowest percentage of Indian births for which both parents were 
identified as Indian, 23 percent for each Area; this may be a 
factor in differences in racial classification, as well. For the 
other Areas the percentage of births for whom both parents were 
Indian ranged from 3 percent for Bemidji to 69 percent for Navajo. 

There is an interesting point that should be noted from Table 
1. On a State by State basis the number of births identified as 
Indian in the linked study was extremely close, if not identical, 
to the number identified from the regular registration file except 
for the States of Arizona and California. For these two States, 
the number of Indian births in the linked file was notably higher. 
Although one might assume that the additional Indian births 
included in the linked file might be the addition of late filed 
certificates, the summary table below disproves this theory. As 
shown below, the total number of births of all races in the linked 
file was no greater than the number in the registration file for 
these two States, eliminating the possibility of the addition of 
late filed certificates. 

One possible factor contributing to this difference might be 
the status of these two States as nonparticipants in the Vital 
Statistics Cooperative Program. For the five nonparticipating 
States, only 50 percent of the birth certificates (the even 
numbered certificates) were coded for the natality file. When an 
infant death was associated with an odd-numbered birth record, that 
record was added to the denominator file. To maintain the same 
total number of birth records in the file, record weights were 
changed from 2 to 1 for the same number of even-numbered records. 
Although the procedure used to make this adjustment was devised to 
minimize the introduction of bias to the file, some bias may have 
resulted. While this accounts for some of the additional Indian 
births found for these two States, further analysis indicates that 
it does not explain all of the additional Indian births. 



Table A. 



Indian Births 
Registration Linked 



Arizona 
California 



5,694 
5,459 



5,818 
5,737 



Total Births, 
All Races 
Registration Linked 

53,785 53,745 

436,143 436,144 



Infant Mortality Rates from the Linked File Compared to 
Registration Data 

Indian infant mortality rates were substantially higher when 
computed from the linked file as shown in Table 1. The rate for 
Reservation States computed from registration data was 10.8 infant 
deaths per 1,000 live births; from the linked file the rate for 
these States was 14.7, 36 percent higher. Considerable variation 
in rates was found by State, with the greatest difference occurring 
for California (over 4 times as great, 2.9 compared to 12.7). 
Although several other States showed increases of this magnitude, 
the actual number of deaths on which these increases were based was 
small (less than 5 deaths) . 

IHS plans to use the linked file routinely in the future to 
compute what are expected to be much more accurate infant mortality 
rates. However, several more years are needed before preparation 
of the linked file catches up to the availability of the regular 
registration file so that this can be accomplished. 

Table 3 compares linked file and registration data by age at 
death. It is apparent from the table that race misclassif ication 
is a problem for each age category. The number of Indian infant 
deaths ranged from 21 percent to 58 percent greater in the linked 
file compared to registration data. The greatest difference was 
found for those dying within 1 to 23 hours after birth, the 
smallest difference for those dying within 7 to 27 days. 

Race reporting on the death certificate was no better for 
those infants dying shortly after birth than for those dying months 
later. Most healthy newborns typically remain in the hospital with 
the mother 2 to 3 days following delivery 4 . The average length of 
stay for an infant with health problems is probably even longer 
than for a healthy one. It would seem logical to assume that an 
infant dying within several days of birth would most likely die in 
the hospital in which it was born and that the birth and death 
certificates would be filed at the same time and signed by the same 



A IHS Direct Hospital Data for FY 1983 shows the average length 
of stay as 2.6 days. 



physician so that information completed on the two documents would 
be the same. However, an examination of data in Table 3 shows 
substantial misclassification for infants dying within 24 hours of 
birth. For infants dying within 1 hour of birth the linked file 
identified 26 percent more as Indian than did the registration 
file. For those newborns dying at least 1 hour but less than 24 
hours after birth the number identified as Indian was 58 percent 
higher in the linked file. Some of these differences may be due to 
transfer of critically ill infants to a more technologically 
sophisticated hospital shortly after birth. 

Table 3 shows age-specific infant mortality rates computed 
from the linked file. Figure 1 compares the difference in rates 
between the linked and registration files. The pattern of change 
for the rates corresponded to the pattern of change in the number 
of deaths by age. 

Table B shows the percentage distribution of deaths by age for 
the linked file compared to the registration file. The proportion 
of deaths occurring in the neonatal (less than 28 days) and 
postneonatal (28 days or more) periods was similar for both files. 

Table B. 



Registration Data 

Percent 
Distribution Number 



Linked Data 



Percent 
Distribution 



Number 



Age at Death 



Less than 1 hour 
1 to 2 3 hr. 

1 to 6 days 
7 to 27 days 

28 days or more 

TOTAL 



9.7 


43 


8.8 


54 


13.3 


59 


15.1 


93 


13.5 


60 


13.8 


85 


13.1 


58 


11.4 


70 


50.3 


223 


50.9 


313 



100.0 



443 



100.0 



615 



CHARACTERISTICS OF INFANT DEATHS 

This section of the report provides an analysis of 
characteristics of Indian infant deaths based on data from the 
linked file. The analysis includes comparison of characteristics 
of Indian infant deaths with U.S. All Races and White infant 
deaths; it also compares linked data with regular registration 
file data for those characteristics that are included in both 
files. 



Characteristics relating to survival chances of infants can be 
categorized in two ways - health characteristics of the infant 
itself and demographic characteristics of the infant's parents 
which can affect the health of the infant before or shortly after 
birth or at any time during the first year of life. 

Health Characteristics of Infant Deaths 

Age at Death 

Table 4 and Figure 2 show the number of infant deaths and 
infant mortality rates by race from the linked file. The higher 
overall infant mortality rate among Indian infants when compared to 
U.S. All Races and White infants was the result of a higher 
postneonatal mortality rate. There was little difference in the 
neonatal rate - 7.2 infant deaths per 1,000 live births for Indian 
infants compared to 7.1 for U.S. All Races and 6.1 for White 
infants. However, for the postneonatal period, Indian infants had 
a mortality rate more than twice the rate for these two other 
racial categories - 7.2 (Indian) compared to 3.8 (All Races) and 
3.2 (White), respectively. The table shows that Indian infants 
were the only racial group about as likely to die during the 
postneonatal as during the neonatal period. Although Black infants 
had an overall infant mortality rate of 18.9, 1.3 times the rate 
for Indian infants they, too, had a lower mortality rate during the 
postneonatal period than did Indian infants- 6.6 compared to 7.4. 

BJrth Weight 

Birth weight is one of the items that is available for infant 
deaths only from the linked file. Since it is not included on the 
death certificate no comparison can be made with the registration 
file. 

Table 5 and Figure 3 compare Indian infant mortality rates by 
birth weight with rates for U.S. All Races, White, and Black. The 
mortality rates for infants of low birth weight (less than 2,500 
grams or 5 lbs. 9 oz . ) were high for each racial category - 
approximately 1 out of 10 of these infants died, regardless of from 
which racial group they came. 

What is most strikingly shown in Figure 3 is that Indian 
babies of normal weight were less likely to benefit from the 
additional weight than infants in other racial categories. Non-low 
birth weight Indian babies were approximately twice as likely to 
die as were White infants and U.S. infants of All Races in this 
weight category. Infant mortality rates for these infants were 
8.5, 4.1, and 4.5 infant deaths per 1,000 live births, 
respectively. 

Table 6 shows a finer breakout by birth weight. American 



Indian survival disadvantage in relation to the race categories 
shown in the table first becomes apparent at 1,500 grams (3 lbs., 
5 oz.) and was most pronounced for infants with birth weight in the 
3,000 to 4,499 grams (6 lbs., 10 oz . to 9 lbs., 14 oz.) range. 
Another noteworthy finding from the table is the relationship of 
mortality among Indian infants compared to Black infants. The 
birth weight-specific mortality rates were higher for Indians than 
for Blacks for low and medium weight infants; however, for infants 
weighing 4,000 grams or more, the mortality rates were higher for 
Black than for Indian babies. 

Table 7 shows neonatal and postneonatal mortality rates by 
birth weight. Neonatal and postneonatal rates were consistent 
among the racial groups shown in the table for the smallest babies 
(less than 1,500 grams or 3 lbs., 4 oz.): one third of these 
tiniest of infants did not survive the neonatal period regardless 
of race. Of infants in this weight category surviving past the 
28th day, there appeared to be no survival advantage for any 
particular racial category. Postneonatal infant mortality rates 
were 41.8 for Indians, 41.4 for Whites, 53.1 for Blacks, and 4 5.8 
for U.S. infants of All Races. 

For infants larger than 1,500 grams but still in the low birth 
weight category, the neonatal mortality rates for Indian, White, 
and U.S All Races infants were approximately the same: 20.2, 20.1, 
and 18.0, respectively. For White infants and U.S. infants of All 
Races, survival chances improved in the postneonatal period, with 
mortality rates decreasing to 11.3 and 12.0, respectively. 
However, no similar improvement was found for American Indian 
infants, the postneonatal mortality rate remaining as high as 
during the neonatal period. 

Infants weighing 2,500 grams or more in all racial categories 
shown in Table 7 experienced relatively low mortality during both 
the neonatal and postneonatal periods. In this weight category 
higher mortality rates occurred in the postneonatal compared to the 
neonatal period. The largest difference in rates between these 
time periods was found for Indian infants, with the postneonatal 
rate over 2.6 times the neonatal rate (6.2 compared to 2.3). In 
fact, the highest mortality rate for normal weight infants in 
either the neonatal or postneonatal period was the postneonatal 
rate of 6.2 for Indian babies. 

Cause of Death 

Table 8 shows the number of Indian infant deaths by cause of 
death from the linked file compared to registration data. It also 
shows cause-specific infant mortality rates computed from each of 
the two files. The cause-specific mortality rates are shown per 
100,000 live births since the numbers of deaths are small when 
broken down by individual causes. Rates based on small numbers 
should be interpreted with caution since differences may be based 



on random fluctuations. 

The additional infant deaths identified in the linked file 
were distributed among all the major causes of death. Differences 
in number of deaths between the linked file and registration data 
ranged from 27 percent to 67 percent for those causes with more 
than 10 deaths in the registration file. Two causes of death for 
Indian infants, sudden infant death syndrome (SIDS) and congenital 
anomalies, far surpassed the other leading causes in terms of the 
number of deaths. The linked file showed 153 Indian babies dying 
from SIDS compared to 99 identified from registration data, an 
increase of 55 percent. The number of deaths from congenital 
anomalies increased by 44 percent, from 77 identified from 
registration data to 111 identified in the linked file. 

Figure 4 shows the relationship between cause-specific 
mortality rates computed from registration data compared to those 
rates computed from the linked file. The figure shows that rates 
increased for each of the causes shown and that there was no major 
re-ranking of causes as a result of the additional deaths 
identified in the linked file. 

A comparison by cause of death by race from the linked study 
is shown in Table 9. Most striking is the substantially higher 
death rate from SIDS among Indian infants when compared to each of 
the racial groupings shown on the table. It was the leading cause 
of death of Indian infants in contrast to White and U.S. infants of 
All Races for whom the leading cause was congenital anomalies. The 
SIDS mortality rate for Indians was 3 times the rate for White 
infants (361.8 compared to 121.5). 

Figure 5 graphically shows a comparison of cause-specific 
rates by race. The mortality rate for Indians was notably higher 
than the rate for White infants and for U.S. infants of All Races 
for most causes. 



Preventable Infant Mortality 

Preventable infant mortality has been defined by Kleinman as 
postneonatal mortality among infants weighing 2,500 grams or more 
at birth excluding deaths from congenital anomalies. 5 Although the 
small size of the one year linked data file precludes development 
of a table crossing these three variables it is obvious from the 
data presented for each of these variables that preventable infant 
mortality is probably a serious problem among Indians. Further 



5 Kleinman, Joel C. , Ph.D., Infant Mortality Among 
Racial/Ethnic Minority Groups, 1983-1984. Morbidity and Mortality 
Weekly Report , Vol. 39/No. SS-3, July 1990, Center for Disease 
Control . 

10 



analysis of "preventable" deaths by characteristics previously 
unavailable but extracted from the birth certificate and now 
included in the linked file might provide some clues on why this is 
a particular problem among Indians. However, analysis of this 
issue must wait until additional years of linked files are 
available in order to have a large enough population of infant 
deaths for more in-depth analysis. 

Factors Purina Pregnancy and Delivery Relating to Health of the 
Infant 

Certain factors affect the health of an infant, including 
receipt of prenatal care, attendant and place of delivery, and 
plurality. Apgar scores reflect the condition of the infant at 
time of delivery. Each of these characteristics is available for 
analysis of infant deaths only from the linked file. 

Prenatal Care 

The timing and guality of prenatal care is an important means 
of influencing the outcome of a pregnancy and an infant's chance of 
survival. Optimally, care should begin during the first trimester. 
Table 10 shows infant mortality rates by month prenatal care began 
by race. Indian infants whose mothers initiated prenatal care 
during the first three months had lower mortality rates than those 
born to mothers who waited until later in pregnancy to begin care. 
Those born to mothers who received no prenatal care had an infant 
mortality rate 3 times that of infants born to mothers who began 
care early. 

Although it is obvious from Table 10 that receiving prenatal 
care early in pregnancy was related to a lower mortality rate for 
an Indian infant, the mortality rate remained high in relation to 
rates for White infants (Figure 6) . White infants whose mothers 
began care as late as the last trimester still experienced lower 
infant mortality rates than Indian infants whose mothers began care 
in the first trimester. The only prenatal care category for which 
White infants fared as poorly as Indian infants was the one in 
which no prenatal care was received by the mother (34.8 and 35.7, 
respectively) . 

Attendant at Birth and Place of Delivery 

Table 11 shows the number of infant deaths and infant 
mortality rates by attendant and place of delivery by race. The 
vast majority of Indian infants who died had been delivered in a 
hospital by a physician (572 of 615) . 

Apaar Score 

The Apgar score was developed by Virginia Apgar, M.D. in 1952 

11 



to evaluate an infant's physical condition at 1 and 5 minutes after 
birth. It serves as an indication of the need for immediate 
medical attention and a predictor of an infant's chances of 
surviving the first year of life. It is based on an evaluation of 
heart rate, respiratory effort, muscle tone, reflex irritability, 
and color. A score of 0-3 indicates that the infant is severely 
depressed; 4-6, moderately depressed; and 7-10 indicates good to 
excellent condition. The 1-minute score is an indication of 
condition at birth; the 5-minute score reflects condition at birth 
and the results of care given during the first 5 minutes after 
birth. The 5-minute score is a better predictor of long-term 
health conditions and survival chances than the 1-minute score. 

Number of deaths and mortality rates by race for 1-minute 
score are shown in Table 12. As one would expect, the higher the 
Apgar score the lower the mortality rate; mortality rates dropped 
sharply with increasing scores. Interestingly, Indian infants with 
scores in the lower range (6 or below) showed no substantially 
greater mortality then infants in the other race categories. 
However, among those with an Apgar score of 7 or above, indicating 
good to excellent health at birth, the mortality rate for Indians 
was twice as high as for White and U.S. infants of All Races (See 
Figure 7) . 

Table 13 shows number of deaths and mortality rates by race 
for 5-minute Apgar score. Again, mortality rates dropped sharply 
as Apgar scores increased, although they did not drop as quickly as 
did the rates for the 1-minute scores. Mortality rates by 5-minute 
score were high (over 100 per 1,000) for infants with scores from 
to 6; for 1-minute scores mortality rates were above 100 only for 
those infants with scores from to 3 . This difference in the 
pattern of mortality rate decline between 1 and 5-minute scores 
reflect successful resuscitative efforts for infants with low 1- 
minute scores. As shown in Figure 8, Indian infants showed no 
greater mortality risk for the lower scores than infants in the 
other race categories; however, mortality rates for Indian infants 
with scores in the excellent range (9 to 10) were approximately 
twice as high as for White infants and U.S. infants of All Races. 

Plurality 

Table 14 shows number of infant deaths and mortality rates by 
plurality and race. Twin and other multiple births experienced 
much higher rates than did single infants regardless of race. 
Shorter gestation periods and lower birth weights among plural 
births contribute to higher mortality rates. 

Age of Mother 

Number of infant deaths and infant mortality rates by age of 
mother by race are shown in Table 15. Mortality rates were 
generally higher for infants born to teenage mothers and to those 

12 



born to mothers over age 40. Optimal survival for Indian infants 
occurred among somewhat older mothers compared to optimal survival 
for White infants. The lowest mortality rate for Indian infants, 
10.3, was found among those born to mothers 35 to 39 years old; 
White infants most likely to survive were those born to mothers age 
25 to 29. The only age category in which Indian infants 
experienced lower mortality rates than White infants was the 
youngest ; however, the rates (18.0 compared to 25.0) were based on 
a relatively small number of births. 

Education of Parents 

Tables 16 and 17 show number of deaths and mortality rates by 
education of mother and father as a measure of socioeconomic 
status. Parents under age 18 were excluded since most would not be 
old enough to finish high school. 

Education of the mother is shown in Table 16. Mortality rates 
decreased with increasing education for both Indian and White 
infants; for both groups mortality rates were more than twice as 
high when comparing the lowest to the highest education categories. 
Rates for Indian infants ranged from 19.7 for those with to 8 
years of education to 8.2 for those with at least 16 years of 
schooling. Mortality rates for Indian infants were higher than for 
White infants and for U.S. infants of All Races for every education 
category as shown in Figure 9 . 

Mortality rates by education of father are shown in Table 17. 
The same patterns of rates by educatior of father emerge as those 
found by education of mother. However, almost half of the Indian 
infant deaths show education of father as not stated, probably as 
a result of the parents not being married at the time of birth of 
the child. 

Marital Status of Mother 

Mortality rates were higher for infants born to unmarried 
mothers for each racial group shown in Table 18. Indian babies 
born to unmarried mothers experienced mortality rates 50 percent 
higher than those born to mothers who were married ( 18.3 and 12.2, 
respectively) . Indian babies experienced higher mortality than 
White infants and U.S. infants of All Races for both marital status 
categories (Figure 10) . 

Live Birth Order 

Table 19 shows the number of deaths and mortality rates by 
live birth order by race. Mortality rates increased with 
increasing birth order for Indian babies, ranging from 13.0 for 
first births to 17.6 for births of 4th or higher order, a 
difference of 35 percent between lowest and highest mortality 
rates. In contrast, the lowest rate for White infants was found 

13 



for those who were second rather than first born; the difference 
was slight, however (8.9 compared to 9.1). Rates were higher for 
Indians than for White or U.S. infants of All Races for each birth 
order (Figure 11) . Rates for Indians were approximately 60 percent 
higher than for Whites, except for first births for which the 
difference was 40 percent, due to the slightly elevated rate for 
White first births. 



14 



APPENDIX A 



National Center for Health Statistics (NCHS) Procedures for Coding 
Race of the Child When the Parents Are of Different Races- 

When only one parent is White the child is assigned the race of the 
other parent. When neither parent is White, the child is assigned 
the race of the father unless the mother is Hawaiian or part- 
Hawaiian in which case the child is assigned Hawaiian. If race is 
missing for one parent, the child is assigned the race of the other 
parent. If race is missing for both parents, the child is assigned 
the race of the preceding child on the electronic data file. 



15 



16 



APPENDIX B 



Indian Health Service Area Offices 




Note: 

Texas is administered by 
Nashville, Oklahoma City 
and Albuquerque. 



MASHVIU-E 




Area Office 



17 



TABLE 1 



NUMBER OF AMERICAN INDIAN & ALASKA NATIVE BIRTHS AND 
INFANT DEATHS BY STATE OF RESIDENCE OF MOTHER FOR 
EACH RESERVATION AND NONRESERVATION STATE, FROM 
THE 1983 LINKED STUDY AND REGULAR REGISTRATION DATA 



RESERVATION 


INFANT 


DEATHS 




BIRTHS 




RATE** 


STATES* 


REG 
46 


LINKED 


REG 


LINKED 


REG 


LINKED 


ALASKA(4%) 


48 


2682 


2681 


17.2 


17.9 


ARIZONA(19%) 


57 


68 


5694 


5818 


10.0 


11.7 


CALIFORNIA(356%) 


16 
2 


73 
8 


5459 
570 


5737 


2.9 


12.7 


COLORADO(300%) 


571 


3.5 


14.0 


CONNECTICUT(0%) 








44 


44 


0.0 


0.0 


FLORIDA(-) 





3 


226 


228 


0.0 


13.2 


IDAHO(0%) 


5 


5 


287 


287 


17.4 


17.4 


IOWA(-33%) 


3 


2 


139 


139 


21.6 


14.4 


KANSAS(233%) 


3 


10 


336 


336 


8.9 


29.8 


LOUISIANA(-50%) 


2 


1 


296 


297 


6.8 


3.4 


MAINE(100%) 


1 


2 


126 


126 


7.9 


15.9 


MICHIGAN(17%) 


6 


7 


735 


735 


8.2 


9.5 


MINNESOTA(27%) 


15 


19 


1268 


1268 


11.8 


15.0 


MISSISSIPPI(33%) 


3 


4 


192 


192 


15.6 


20.8 


MONTANA(6%) 


17 


18 


1438 


1438 


11.8 


12.5 


NEBRASKA(125%) 


4 


9 


354 


354 


11.3 


25.4 


NEVADA(25%) 


4 


5 


498 


499 


8.0 


10.0 


NEWMEXICO(12%) 


42 


47 


3636 


3612 


11.6 


13.0 


NEWYORK(14%) 


7 


8 


728 


728 


9.6 


11.0 


NORTH DAKOTA(42%) 


12 


17 


844 


844 


14.2 


20.1 


N. CAROLINA(10%) 


29 


32 


1585 


1586 


18.3 


20.2 


OKLAHOMA(63%) 


46 


75 


5497 


5496 


8.4 


13.6 


OREGON(0%) 


4 


4 


698 


699 


5.7 


5.7 


PENNSYLVANIA(-) 





2 


144 


144 


0.0 


13.9 


RHODE ISLAND(300%) 


1 


4 


94 


94 


10.6 


42.6 


SOUTH DAKOTA(-4%) 


46 


44 


1815 


1816 


25.3 


24.2 


TEXAS(0%) 


4 


4 


542 


542 


7.4 


7.4 


UTAH (50%) 


4 


6 


650 


653 


6.2 


9.2 


WASHINGTON(32%) 


25 


33 


1744 


1744 


14.3 


18.9 


WISCONSIN(30%) 


20 


26 


880 


880 


22.7 


29.5 


WYOMING(-33%) 


3 


2 


320 


320 


9.4 


6.3 


SUBTOTAL(37%) 


427 


586 


39521 


39908 


10.8 


14.7 



"Figure shown in ( ) is the percent difference in number of deaths between the registration 
and linked files- (-) indicates computation of percent based on infant deaths 
**Rate= Infant Deaths/1 ,000 Live Births 



18 



TABLE 1 (Continued) 



NUMBER OF AMERICAN INDIAN & ALASKA NATIVE BIRTHS AND 
INFANT DEATHS BY STATE OF RESIDENCE OF MOTHER FOR 
EACH RESERVATION AND NONRESERVATION STATE, FROM 





THE 1983 LINKED STUDY AND REGULAR REGISTRATION DATA 


NONRESERVATION 


INFANT 


DEATHS BIRTHS 




RATE" 


STATES 


REG 



LINKED REG LINKED 


REG 
0.0 


LINKED 


ALABAMA(-) 


38 38 


0.0 


ARKANSAS(100%) 


1 


2 136 136 


7.4 


14.7 


DELAWARE(-) 





9 8 


0.0 


0.0 


DISTRICT OF COL(-) 





7 14 


0.0 


0.0 


GEORGIA(50%) 


2 


3 75 83 


26.7 


36.1 


HAWAII(400%) 


1 


5 264 264 


3.8 


18.9 


ILLINOIS(0%) 


2 


2 327 327 


6.1 


6.1 


INDIAN A(-1 00%) 


1 


114 114 


8.8 


0.0 


KENTUCKY(-) 





1 53 53 


0.0 


18.9 


MARYLAND(-) 





2 149 156 


0.0 


12.8 


MASSACHUSETTS(0%) 


2 


2 167 169 


12.0 


11.8 


MISSOURI(0%) 


2 


2 170 170 


11.8 


11.8 


NEW JERSEY(400%) 


1 


5 261 259 


3.8 


19.3 


N. HAMPSHIRE(-) 





17 17 


0.0 


0.0 


OHIO(-33%) 


3 


2 288 288 


10.4 


6.9 


SOUTH CAROLINA(0%) 


1 


1 84 85 


11.9 


11.8 


TENNESSEE(-) 





1 59 59 


0.0 


16.9 


VERMONT(-) 





7 7 


0.0 


0.0 


VIRGINIA(-) 





1 123 126 


0.0 


7.9 


WEST VIRGINIA(-) 





8 8 


0.0 


0.0 


SUBTOTAL(81%) 


16 


29 2356 2381 


6.8 


12.2 



TOTAL 



443 



615 



41877 42289 



10.6 



14.5 



"Figure shown in ( ) is the percent difference in number of deaths between the registration 
and linked files- (-) indicates computation of percent based on infant deaths 
**RATE= Infant Deaths/1 ,000 Live Births 



19 



TABLE 2 



NUMBER AND PERCENT OF AMERICAN INDIAN & ALASKA NATIVE 
BIRTHS BY RACE OF PARENTS, 1983 REGISTRATION DATA 



BOTH PARENTS 



FATHER ONLY 



MOTHER ONLY 



NO. 



% 



NO. 



% 



NO. 



ALL AREAS 


12165 


42.8 


4405 


15.5 


11836 


41.7 


ABERDEEN 


1182 


45.4 


183 


7.0 


1236 


47.5 


ALASKA 


1018 


38.0 


289 


10.8 


1375 


51.3 


ALBUQUERQUE 


727 


49.4 


112 


7.6 


633 


43.0 


BEMIDJI 


444 


30.5 


277 


19.0 


737 


50.6 


BILLINGS 


812 


55.4 


208 


14.2 


447 


30.5 


CALIFORNIA 


362 


23.4 


580 


37.5 


606 


39.2 


NASHVILLE 


286 


38.5 


138 


18.6 


318 


42.9 


NAVAJO 


3653 


68.9 


93 


1.8 


1560 


29.4 


OKLAHOMA CITY 


1289 


23.1 


1603 


28.8 


2683 


48.1 


PHOENIX 


1573 


54.6 


350 


12.1 


959 


33.3 


PORTLAND 


514 


23.4 


511 


23.3 


1173 


53.4 


TUCSON 


305 


64.2 


61 


12.8 


109 


23.0 



2Q 



TABLE 3 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY AGE AT DEATH, AMERICAN INDIAN & ALASKA 
NATIVE, 1983 LINKED STUDY, COMPARED TO 1983 
REGISTRATION DATA 







Infant Deaths 




Percent 




Reaistered 


Linked 


Difference 


AGE AT DEATH 










Less than 1 hr. 


43 




54 


25.6% 


1 to 23 hrs. 


59 




93 


57.6% 


1 to 6 days 


60 




85 


41.7% 


7 to 27 days 


58 




70 


20.7% 


28 days or more 


223 




313 


40.4% 



TOTAL 



443 



615 



38.8% 



Infant Mortality Rate" 



Less than 1 hr. 


1.0 


1.3 


24.4% 


1 to 23 hrs. 


1.4 


2.2 


56.1% 


1 to 6 days 


1.4 


2.0 


40.3% 


7 to 27 days 


1.4 


1.7 


19.5% 


28 days or more 


5.3 


7.4 


39.0% 


TOTAL 


10.6 


14.5 


37.5% 



'Number of infant deaths per 1 ,000 live births 



21 



TABLE 4 



AGE AT DEATH 
Less than 1 hr. 
1 to 23 hrs. 
1 to 6 days 
7 to 27 days 

Subtotal 
28 days or more 
Total 

Less than 1 hr. 
1 to 23 hrs. 
1 to 6 days 
7 to 27 days 

Subtotal 
28 days or more 
Total 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY AGE AT DEATH, AMERICAN INDIAN & 
ALASKA NATIVE, COMPARED TO SELECTED RACES, 
1983 LINKED STUDY 



Indian & 
Alas Nat 



All Races White 



INFANT DEATHS 



Black 



54 

* 


4216 


2962 


1108 


93 


11018 


7292 


3419 


85 


6472 


4620 


1619 


70 


4049 


2929 


1050 


302 


25755 


17803 


7196 


313 


13856 


9310 


3882 



615 



39611 



27113 



11078 



INFANT MORTALITY RA TE* 



1.3 


1.2 


1.0 


1.9 


2.2 


3.0 


2.5 


5.8 


2.0 


1.8 


1.6 


2.8 


1.7 


1.1 


1.0 


1.8 


7.1 


7.1 


6.1 


12.3 


7.4 


3.8 


3.2 


6.6 


4.5 


10.9 


9.3 


18.9 



'Number of Infant Deaths per 1 ,000 Live Births 



22 



TABLE 5 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY RATES 
BY SELECTED BDtTH WEIGHT CATEGORIES, AMERICAN INDIAN 
& ALASKA NATIVE, COMPARED TO SELECTED RACES, 1983 
LINKED STUDY 



Birth Weight- 
in grams 



Less than 2,500 
2,500 or more 
Not stated 



Indian & 








Alas Nat 


All Races 
Infant Deaths 


White 


Black 


262 


23178 


15220 


7212 


335 


15362 


11160 


3479 


18 


1164 


733 


387 



Total 



615 



39704 



27113 



11078 



Infant Mortality Rate * 



Less than 2,500 
2,500 or more 
Not stated 



95.9 


93.5 


92.4 


98.0 


8.5 


4.5 


4.1 


6.8 


195.7 


216.1 


176.7 


380.9 



Total 



14.5 



10.9 



9.3 



18.9 



•Number of infant deaths per 1 ,000 live births 



23 



TABLE 6 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY BIRTH WEIGHT, AMERICAN INDIAN & ALASKA 
NATIVE, COMPARED TO SELECTED RACES, 1983 LINKED 
STUDY 



Birth Weight, 
in grams 



499 or less 

500-999 

1000-1499 

1500-1999 

2000-2499 

2500-2999 

3000-3499 

3500-3999 

4000-4499 

4500-4999 

5000+ 

Not Stated 



Indian & 




Alas Nat 


All Races 




Infant Deaths 


31 


3938 


98 


9584 


42 


3525 


37 


2690 


54 


3441 


87 


4998 


143 


5798 


81 


3293 


20 


930 


4 


229 





114 


18 


1164 



White 



Black 



2296 

6030 

2573 

1912 

2409 

3424 

4155 

2570 

751 

184 

76 

733 



1534 

3279 

834 

673 

892 

1350 

1348 

563 

143 

38 

37 

387 



Total 



615 



39704 



27113 



11078 



Infant Mortality Rate * 



499 or less 


885.7 


885.7 


890.3 


877.1 


500-999 


550.6 


577.0 


597.3 


545.0 


1000-1499 


173.6 


158.4 


179.4 


116.8 


1500-1999 


70.9 


56.8 


61.0 


46.9 


2000-2499 


30.8 


21.9 


22.7 


20.1 


2500-2999 


13.5 


8.5 


8.2 


9.6 


3000-3499 


9.2 


4.3 


3.9 


6.0 


3500-3999 


6.5 


3.1 


2.8 


4.9 


4000-4499 


5.0 


2.8 


2.6 


5.7 


4500-4999 


5.0 


3.8 


3.4 


9.6 


5000+ 


0.0 


14.0 


10.6 


51.0 


Not Stated 


195.7 


216.1 


176.7 


380.9 



Total 



14.5 



10.9 



9.3 



18.9 



'Number of infant deaths per 1 ,000 live births 



24 



TABLE 7 



NUMBER OF NEONATAL AND POSTNEONATAL DEATHS AND INFANT MORTALITY RATES 
BY BIRTH WEIGHT, AMERICAN INDIAN AND ALASKA NATIVE, COMPARED TO SELECTED 
RACES, 1983 LINKED STUDY 





Indian 


* 
















Alas 


Nat. 


All 


Races 


White 




Black 




Birth Weiqht. 


Neonatal 


Postneo. 


Neonatal 


Postneo. 


Neonatal 


Postneo. 


Neonatal 


Postneo. 


in qrams 










Infant Deaths 








Less than 1 ,500 


152 


19 


15062 


1985 


9780 


1119 


4855 


792 


1 ,500 to 2,499 


46 


45 


3677 


2454 


2767 


1554 


762 


803 


2,500 or more 


89 


246 


6012 


9350 


4571 


6589 


1208 


2271 


Not stated 


15 


3 


1097 


67 


685 


48 


371 


16 



Total 



302 



313 



25848 



13856 



17803 



9310 



7196 



3882 



Infant Mortality Rate * 



Less than 1 ,500 


334.1 


41.8 


347.8 


45.8 


362.0 


41.4 


325.7 


53.1 


1 ,500 to 2,499 


20.2 


19.8 


18.0 


12.0 


20.1 


11.3 


13.0 


13.7 


2,500 or more 


2.3 


6.2 


1.8 


2.8 


1.7 


2.4 


2.4 


4.4 


Not stated 


163.0 


32.6 


203.7 


12.4 


165.1 


11.6 


365.2 


15.7 



Total 7.1 7.4 

"Number of infant deaths per 1 ,000 live births 



7.1 



3.8 



6.1 



3.2 



12.3 



6.6 



to 



TABLE 8 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY CAUSE OF DEATH, AMERICAN INDIAN AND 
ALASKA NATIVE, 1983 LINKED STUDY, COMPARED TO 
1983 REGISTRATION DATA 



CAUSE OF DEATH 



INFANT DEATHS 



Registered Linked 



INFANT MORTALITY 
RATE* 

Registered Linked 



Sudden infant death syndrome 
Congenital anomalies 
Respiratory distress syndrome 
Disorders related to short 

gestation & low brthwght 
Accidents 

Pneumonia & influenza 
Infections specific 

to perinatal period 
Intrauterine hypoxia 

& birth asphyxia 
Newborn affected by 

maternal complications 
of pregnancy 
Newborn affected by 

complications of placenta 
cord & membranes 
Meningitis 
Septicemia 

All other causes 

Total 



99 


153 


77 


111 


33 


44 


22 


30 


12 


20 


12 


19 


10 


16 


11 


14 



10 



8 
7 
2 


10 
8 
6 


144 


174 


443 


615 



236.4 


361.8 


183.8 


262.4 


78.8 


104.0 


52.5 


70.9 


28.7 


47.3 


28.7 


44.9 


23.9 


37.8 


26.3 


33.1 



14.3 



23.6 



19.1 23.6 

16.7 18.9 

4.8 14.2 

343.8 411.4 

1057.7 1454.1 



"Number of infant deaths per 100,000 live births 



26 



TABLE 9 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY RATES 
BY CAUSE OF DEATH, AMERICAN INDIAN & ALASKA NATIVE, 
COMPARED TO SELECTED RACES, 1983 LINKED STUDY 



Indian & 
Alas Nat 



All 
Races 



White 



Black 



Indian & 
Alas Nat 



All 

Races 



White 



Black 



CAUSE OF DEATH 



INFANT DEATHS 



INFANT MORTALITY RA TE' 



Sudden infant death syndrome 
Congenital anomalies 
Respiratory distress syndrome 
Disorders related to short 

gestation & low brthwght 
Accidents 

Pneumonia & influenza 
Infections specific 

to perinatal period 
Intrauterine hypoxia 

& birth asphyxia 
Newborn affected by 

maternal complications 
of pregnancy 
Newborn affected by 

complications of placenta 
cord & membranes 
Meningitis 
Septicemia 

All other causes 

Total 



"Number of infant deaths per 100,000 live births 



153 


5271 


3533 


1478 


111 


8576 


6759 


1452 


44 


3600 


2565 


928 


30 


3235 


1833 


1326 


20 


870 


573 


262 


19 


732 


438 


252 


16 


845 


589 


218 


14 


1182 


805 


332 



10 



1435 



977 



10 


842 


599 


8 


310 


186 


6 


281 


174 


174 


12525 


8082 


615 


39704 


27113 



423 



212 

111 

91 

3993 

11078 



361.8 


144.7 


121.5 


252.4 


262.4 


235.4 


232.4 


248.0 


104.0 


98.8 


88.2 


158.5 


70.9 


88.8 


63.0 


226.5 


47.3 


23.9 


19.7 


44.7 


44.9 


20.1 


15.1 


43.0 


37.8 


23.2 


20.3 


37.2 


33.1 


32.4 


27.7 


56.7 



23.6 

23.6 
18.9 
14.2 

411.4 

1454.1 



39.4 



23.1 
8.5 
7.7 

343.8 

1089.9 



33.6 

20.6 
6.4 
6.0 

277.9 

932.3 



72.2 

36.2 
19.0 
15.5 

682.0 

1892.0 



to 

-.1 



TABLE 10 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY MONTH PRENATAL CARE BEGAN, AMERICAN 
INDIAN & ALASKA NATIVE, COMPARED TO SELECTED 
RACES, 1983 LINKED STUDY 



MONTH 

PRENATAL CARE 

BEGAN 



Indian & 
Alas Nat 



All Races 



INFANT DEATHS 



White 



Black 



1st &2nd months 
3rd month 
4th-6th month 
7th-9th month 
No prenatal care 
Not stated 



192 


17771 


13239 


3924 


109 


8014 


5556 


2177 


162 


7747 


4687 


2719 


67 


1567 


944 


521 


47 


2474 


1291 


1109 


38 


2131 


1396 


628 



Total 



615 



39704 



27113 



11078 



INFANT MORTALITY RA TE' 



1st & 2nd months 
3rd month 
4th-6th month 
7th-9th month 
No prenatal care 
Not stated 



12.8 


9.4 


8.3 


17.9 


11.5 


9.6 


8.3 


16.6 


14.4 


11.9 


10.3 


16.6 


17.3 


11.1 


9.9 


14.2 


35.7 


42.5 


34.8 


59.5 


27.0 


28.3 


25.4 


39.9 



Total 



14.5 



10.9 



9.3 



18.9 



'Number of infant deaths per 1 ,000 live births 



28 



TABLE 1 1 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY ATTENDENT AT BIRTH & PLACE OF DELIVERY, 
AMERICAN INDIAN & ALASKA NATIVE, COMPARED TO 
SELECTED RACES, 1983 LINKED STUDY 



Attendent & 


Indian & 








Place of 


Alas Nat 


All Races 


White 


Black 


Delivery 




INFANT DEATHS 






In hospital 










Physician 


572 


38345 


26270 


10645 


Midwife 


18 


433 


262 


143 


Other attendent 


14 


177 


150 


92 


Not in hospital 










Physician 


2 


226 


152 


107 


Midwife 





84 


78 


4 


Other attendent 


8 


268 


177 


80 


Unknown 


1 


131 


24 


7 


Total 


615 


39664 


27113 


11078 



INFANT MORTALITY RA TE' 



In hospital 










Physician 


15.0 


10.9 


9.4 


19.0 


Midwife 


7.0 


6.0 


5.3 


8.2 


Other attendent 


13.6 


9.5 


11.1 


30.4 


Not in hospital 










Physician 


17.1 


20.0 


17.4 


52.6 


Midwife 


0.0 


5.0 


5.0 


5.3 


Other attendent 


39.6 


21.6 


17.4 


48.4 


Unknown 


26.3 


62.8 


15.5 


21.5 


Total 


14.5 


10.9 


9.3 


18.9 



'Number of infant deaths per 1 ,000 live births. 



29 



TABLE 12 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY 1 MINUTE APGAR SCORE, AMERICAN INDIAN 
& ALASKA NATIVE, COMPARED TO SELECTED RACES, 
1983 LINKED STUDY 



Apqar 
Score 



Indian & 
Alas Nat 



All Races 



White 



Black 



INFANT DEATHS 





1 to 3 
4 to 6 
7 to 8 

9 to 10 
Not Stated 



13 


821 


559 


237 


131 


13585 


8873 


4362 


60 


4919 


3456 


1329 


156 


6678 


4660 


1759 


73 


3896 


2473 


1261 


182 


9805 


7092 


2130 



Total 



615 



39704 



27113 



11078 



INFANT MORTALITY RA TE' 





1 to 3 
4 to 6 
7 to 8 

9 to 10 
Not Stated 



406.3 


402.5 


407.7 


399.0 


161.7 


206.5 


195.6 


2?7.0 


24.0 


23.4 


21.2 


32.6 


9.8 


5.1 


4.4 


8.4 


6.8 


3.2 


2.6 


5.8 


14.7 


11.5 


10.3 


21.1 



Total 



14.5 



10.9 



9.3 



18.9 



'Number of infant deaths per 1 ,000 live births. 



30 



TABLE 13 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY 5 MINUTE APGAR SCORE, AMERICAN INDIAN 
& ALASKA NATIVE COMPARED TO SELECTED RACES, 
1983 LINKED STUDY 





Indian & 








ADOar 


Alas Nat 


All Races 


White 


Black 


Score 




Infant deaths 









13 


1195 


803 


363 


1 to 3 


82 


9085 


5846 


3011 


4 to 6 


61 


4982 


3439 


1410 


7 to 8 


63 


4923 


3462 


1322 


9 to 10 


213 


9364 


6255 


2714 


Not Stated 


183 


10155 


7308 


2258 



Total 



615 



39704 



27113 



11078 



Infant Mortality Rate ' 






500.0 


612.2 


634.8 


585.5 


1 to 3 


471.3 


595.7 


599.9 


591.0 


4 to 6 


129.0 


126.3 


123.3 


134.7 


7 to 8 


17.7 


16.4 


14.8 


23.4 


9 to 10 


8.3 


3.8 


3.2 


6.6 


Not Stated 


14.8 


11.9 


10.6 


22.3 



Total 



14.5 



10.9 



9.3 



18.9 



"Number of infant deaths per 1 ,000 live births 



31 



TABLE 14 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY PLURALITY, AMERICAN INDIAN & ALASKA 
NATIVE COMPARED TO SELECTED RACES, 1983 LINKED 
STUDY 





Indian & 






Alas Nat 


All Races 


PLURALITY 


i 


'NFANTDE 


Single Birth 


562 


35561 


Twin Births 


52 


3912 


Other Multiple 


1 


231 


Births 







White 



24252 

2677 

184 



Black 



9911 

1122 

45 



Total 



615 



39704 



27113 



11078 



INFANT MORTALITY RA TE* 



Single Birth 


13.5 


10.0 


8.5 


17.4 


Twin Births 


68.3 


54.0 


47.9 


79.3 


Other Multiple 


62.5 


146.3 


141.8 


200.9 


Births 











Total 



14.5 



10.9 



9.3 



18.9 



•Number of infant deaths per 1000 live births 



32 



TABLE 15 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY AGE OF MOTHER, AMERICAN INDIAN & 
ALASKA NATIVE, COMPARED TO SELECTED RACES, 
1983 LINKED STUDY 



Indian & 
Alas Nat 



All Races 



White 



Black 



AGE OF MOTHER 



INFANT DEATHS 



Under 15 years 
15 to 17 years 
18 to 19 years 
20 to 24 years 
25 to 29 years 
30 to 34 years 
35 to 39 years 
40 to 44 years 
45 to 49 years 



3 


274 


101 


166 


56 


3042 


1707 


1251 


100 


4630 


2932 


1546 


221 


13343 


9066 


3863 


138 


10482 


7516 


2550 


67 


5717 


4171 


1231 


18 


1847 


1350 


404 


12 


340 


253 


63 





29 


17 


4 



Total 



615 



39704 27113 11078 



INFANT MORTALITY RATE' 



Under 15 years 


18.0 


28.1 


25.0 


30.6 


15 to 17 years 


17.7 


17.6 


15.6 


21.5 


18 to 19 years 


18.3 


14.6 


12.8 


19.7 


20 to 24 years 


14.0 


11.5 


9.9 


19.0 


25 to 29 years 


13.1 


9.1 


7.9 


17.8 


30 to 34 years 


13.1 


9.1 


8.0 


17.4 


35 to 39 years 


10.3 


10.2 


9.2 


18.1 


40 to 44 years 


36.8 


13.1 


12.5 


15.7 


45 to 49 years 


0.0 


25.0 


21.0 


20.2 



Total 



14.5 



10.9 



9.3 



18.9 



"Number of infant deaths per 1 ,000 live births 



33 



TABLE 16 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY MOTHER'S EDUCATION FOR WOMEN 18 YEARS 
OR OLDER, AMERICAN INDIAN & ALASKA NATIVE, 
COMPARED TO SELECTED RACES, 1983 LINKED STUDY 



Years of School 
Completed by 
Mother 



Indian & 
Alas Nat 



All Races 



INFANT DEATHS 



White 



Black 



to 8 years 
9 to 1 1 years 

1 2 years 

13 to 15 years 

1 6 or more years 
Not stated 



30 

143 

200 

64 

12 

107 



1210 


847 


6236 


3626 


12508 


8591 


4928 


3486 


3121 


2567 


8385 


6188 



277 
2416 
3555 
1303 

442 
1668 



Total 



556 



36388 



25305 



9661 



INFANT MORTALITY RA TE ' 



to 8 years 


19.7 


14.2 


13.3 


19.7 


9 to 1 1 years 


15.9 


15.8 


13.1 


23.3 


1 2 years 


14.4 


10.5 


8.9 


17.5 


1 3 to 1 5 years 


12.7 


9.1 


7.8 


16.0 


16 or more years 


8.2 


7.0 


6.5 


13.3 


Not stated 


13.3 


10.5 


9.5 


19.3 



Total 14.3 10.5 

•Number of infant deaths per 1 ,000 live births. 



9.1 



18.5 



3- 



TABLE 17 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY FATHER'S EDUCATION FOR MEN 18 YEARS 
OR OLDER, AMERICAN INDIAN & ALASKA NATIVE, 
COMPARED TO SELECTED RACES, 1983 LINKED STUDY 



Years of School 
Completed by 
Father 



Indian & 
Alas Nat 



All Races 



INFANT DEATHS 



White 



Black 



to 8 years 
9 to 1 1 years 

12 years 

13 to 15 years 
16 or more years 
Not stated 



25 
88 

150 
45 
17 

285 



1045 
4039 
9883 
3864 
3943 
16639 



808 
2961 
7374 
3025 
3406 
9349 



178 
954 

2215 
722 
383 

6533 



Total 



610 



39413 



26923 



10985 



INFANT MORTALITY RA TE' 



to 8 years 


17.1 


12.7 


12.0 


19.0 


9 to 1 1 years 


15.9 


13.9 


12.6 


20.0 


12 years 


13.2 


9.9 


8.9 


15.8 


13 to 15 years 


10.7 


8.6 


7.8 


14.5 


16 or more years 


9.4 


6.9 


6.6 


12.5 


Not stated 


16.3 


13.5 


10.9 


21.6 



Total 



14.6 



10.9 



9.3 



18.9 



"Number of infant deaths per 1 ,000 live births. 



35 



36 



TABLE 18 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY RATES BY 
MARITAL STATUS OF MOTHER, AMERICAN INDIAN & ALASKA 
NATIVE, COMPARED TO SELECTED RACES, 1983 LINKED STUDY 



Marital 
Status of 
Mother 



Indian & 
Alas Nat 



AM Races 



INFANT DEATHS 



White 



Black 



Married 
Unmarried 



315 
300 



26832 
12872 



21886 
5227 



3850 
7228 



Total 



615 



39704 



27113 



11078 



INFANT MORTALITY RA TE* 



Married 
Unmarried 



12.2 
18.3 



9.2 
17.4 



8.6 
14.1 



15.7 
21.2 



Total 



14.5 



10.9 



9.3 



18.9 



•Number of infant deaths per 1 ,000 live births 



TABLE 19 



NUMBER OF INFANT DEATHS AND INFANT MORTALITY 
RATES BY LIVE BIRTH ORDER, AMERICAN INDIAN & 
ALASKA NATIVE, COMPARED TO SELECTED RACES, 
1983 LINKED STUDY 



Live Birth 
Order 



Indian & 
Alas Nat 



All Races 



White 



Black 



INFANT DEATHS 



1st birth 
2nd birth 
3rd birth 
4th or more 
Not Stated 



198 


15938 


11262 


4142 


176 


12249 


8659 


3106 


110 


6238 


4114 


1872 


128 


4871 


2800 


1843 


3 


408 


278 


115 



Total 



615 



39704 



27113 



11078 



INFANT MORTALITY RA TE' 



1st birth 
2nd birth 
3rd birth 
4th or more 
Not Stated 



13.0 


10.4 


9.1 


18.0 


14.4 


10.3 


8.9 


18.1 


14.9 


11.2 


9.5 


19.1 


17.6 


13.9 


11.3 


22.3 


23.4 


30.9 


18.5 


33.0 



Total 



14.5 



10.9 



9.3 



18.9 



"Number of infant deaths per 1 ,000 live births. 



37 



38 



FIGURE 1. 

Infant Mortality Rates by Age at Death 

for American Indians/Alaska Natives, 

1983 Registration Data and 1983 Linked Study 



Rate per 1,000 live births 
10" 



5- 



1 983 Registration Data 
E2 1983 Linked Study 




<lHr 1-23 Hrs 1-6 Days 7-27 Days <28 Days 28 Days 

(Neonatal) or more 

(Postneonatal) 

Age at Death 



39 



FIGURE 2. 

Infant Mortality Rates by Age at Death 

for American Indians/ Alaska Natives 

Compared to Selected Races, 1983 Linked Study 



Rate per 1,000 live births 

15 -i 



10- 



5- 



■ 


American Indian/Alaska Native 


B 


All Races 


Hgg 


White 


□ 


Black 



123 




<1 Hr 1-23 Hrs 



1-6 Days 7-27 Days <28Days 28 Days 

(Neonatal) or More 
Age at Death (Postneonatal) 



40 



FIGURE 3. 

Infant Mortality Rates for Infants 

Weighing 2500 Grams or More, 

American Indians/ Alaska Natives 

Compared to Selected Races, 

1983 Linked Study 



Rate per 1,000 live births 

10 



5- 




American All White 
Indian/ Races 
Alaska 
Native 



Black 



41 



FIGURE 4. 

Infant Mortality Rates for American 

Indians/ Alaska Natives by Cause of Death, 

1983 Registration Data and 1983 Linked Study 



Sudden Infant 
Death Syndrome 

Congenital 
Anomalies 

Respiratory Distress 
Syndrome 

Disorders Related bp? 
to Short Gest. & 
Low Birth Weight 

Accidents 



Pneumonia & 
Influenza 




236.4 



1983 Linked Study 
■ 1 983 Registration Data 



100 



200 



300 



400 



Rate per 100,000 Live Births 



FIGURE 5. 

Infant Mortality Rates by Cause 

for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 



Sudden Infant 
Death Syndrome 



Respiratory Distress 
Syndrome 




361.8 



Disorders Related 
to Short Gest. & 
Low Birth Weight 

Accidents 



Pneumonia & 
Influenza 



American Indian/Alaska Native 
All Races 

White 
□ Black 



100 200 300 

Rate per 100,000 Live Births 



400 



43 



FIGURE 6. 
Infant Mortality Rates by Month Prenatal Care 

Began for American Indians/Alaska Natives 
Compared to Selected Races, 1983 Linked Study 

Rate per 1,000 Live Births 

6(h 



59.5 



50- 



40- 



30- 



20- 



American Indian/Alaska Native 
All Races 
■ White 
□ Black 



17.9 



16.6 



16.6 



17.3 





1st & 2nd 


3rd 


4th-6th 


7th-9th 


No 


Months 


Month 


Month 


Month 


Prenatal Care 



44 



FIGURE 7. 
Infant Mortality Rates by 1 Minute Apgar Score 

for American Indians/ Alaska Natives 
Compared to Selected Races, 1983 Linked Study 



\rsjyssssssjyssssssssssssssssssssssssA 




9 to 10 



406.3 
T402.5 

407.7 
j 399.0 



■ 


American Indian/Alaska Native 


E2 


All Races 




White 


□ 


Black 



100 200 300 

Rate per 1,000 Live Births 



400 



500 



45 



FIGURE 8. 
Infant Mortality Rates by 5 Minute Apgar Score 

for American Indians/ Alaska Natives 
Compared to Selected Races, 1983 Linked Study 



500.0 



'SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSJ 




■ 


American Indian/Alaska Native 


□ 


All Races 


1 


White 


D 


Black 



300 400 500 600 700 



Rate per 1,000 Live Births 



4r 



FIGURE 9. 

Infant Mortality Rates by Mother's Education 

for Mothers Age 18 Years or Older, 

American Indians/ Alaska Natives 

Compared to Selected Races, 1983 Linked Study 



25 i 



| American Indian/Alaska Native 
Q All Races 
| White 
1 Black 




0to8 
Years 



9 to 11 
Years 



12 
Years 



1 3 to 1 5 16 or More 
Years Years 



Years of School Completed By Mother 



47 



FIGURE 10. 

Infant Mortality Rates by Marital Status of Mother 

for American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 



c 

r 
to 

> 



o 

8 







Married Unmarried 

Marital Status of Mother 



■ American Indian/ 

Alaska Native 
All Races 
H White 
□ Black 



48 



FIGURE 11. 

Infant MortalityRates by Live Birth Order 

For American Indians/Alaska Natives 

Compared to Selected Races, 1983 Linked Study 




■ 


American Indians/ 




Alaska Natives 





All Races 


s 


White 


I 


Black 



1st Birth 2nd Birth 3rd Birth 4th Birth 

or More 

Live Birth Order 



49 



♦ , 



Office or Mil j«ce Center 

Knowledge Center 

1101 Wootton Parkway, Suite 650 

Rockville, MD 20862 

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